Preventing Surgical Site Infections In Post-Operative Care: Literature Review

The current assignment focuses upon the occurrence of surgical site infections in post-operative care.  The health burden on the overall healthcare system due to surgical infections has been estimated to be around 2.8% annually. The physical environment within which the support and care services are provided to the patient, the lack of sufficient skills and awareness within the nursing professionals along with insufficient reporting of the infections behind closed doors has made taking measures for prevention of surgical site infections very important.

The scenario presented above had been used to build a research question based upon which the study has been conducted.

Research question: 

The incidents of surgical site infections are high within a post-operative care? 

Conduct a literature search (using Medline AND CINAHL databases) and identify literature relevant to the research question. Append the search history to the assignment

Write a Literature Review that describes what is already known about your research question  (approx. word count 1,500)

There has been recent rise in the number of surgical site infections globally. Some of these have been affecting the quality of healthcare globally. Most often the chances of infection are high within a post operative care. This could be attributed to the catherer induced central line associated blood infection, failure to follow effective hygiene standards   within the post-operative setup which results in the development of  Staphylococcus aureus bacteraemia (SAB).  It is the most common cause of surgical site infections within peri as well as post-operative care.

In this  respect, some of the  aspects have been highlighted  such as  situation  awareness  which  reduces the  chances of  occurrence serious  infections within an intensive care unit. The situation awareness is a non-technical human skill which has been currently emerged within the healthcare organizations.  It could be further explained based upon a hierarchical structure which comprises of – perception, comprehension and projection. In this respect, situation awareness  is making sense of “ what is happening?”, making sense of “what is  going on?” and predicting future events based upon the current observations. As suggested by Murray (2017), individual as well as team self awareness in important for maintaining optimum standards of care. Some of these skills are implemented within the peri-operative nurses in order to improve the standards or the quality of care.

One of the vital nursing roles which could be highlighted over here is the prevention of surgical site infections. Reports suggest that there are approximately 200,000 hospital re-admissions each year with surgical site infections. Hence it places importance upon the adoption of proper aseptic techniques within an operative setup.  As mentioned by Foran (2015), such infections alone account to 40% of the overall healthcare costs. Therefore, emphasis has been placed upon infection prevention through implementation of aseptic techniques. As peer the Australian College of Operating Room Nurses (ACORN) the asepsis training to the nursing professionals are to be rendered through operating room experience.

 In some cases, women discharged after child delivery through caesarean sections have been seen to suffer from surgical site infections.  As suggested by Smith (2017), the women should be provided with antibiotic prophylaxis prior to incision as this reduces the chances of infection. In this respect, a number of aspects have been   proposed for management of the high rates of surgical site infections. Some of these are using a bundle approach, sharing responsibilities and adhering to best practices. The care bundles consist of three to five activities that promote standardised care. The care bundles have been further divided into – ventilator bundle, sepsis bundle and central line bundle. As argued by Gillespie  et al. (2015), the multifaceted   nature of care bundles makes it difficult to identify the factor which brought about the   change outcome. One of the common ideas promoted across all the care bundles was antibiotic prophylaxis. These are based on providing antimicrobial therapy before and after the commencement of surgical processes. As supported by Barie (2009), the multifaceted nature of the care bundles made it difficult to identity which factor reduced the rate of infection. The care bundle approach centres on monitoring compliance.  It was difficult to find which particular component enhanced teamwork and collaboration within an acute care setup.

One of the most crucial components in reducing the rate of surgical site infections are sharing the responsibility for support and care services within various stakeholders involved in the care process. It is aimed at providing patient centred care at in early post operative care. It puts sufficient emphasis upon the efficient distribution tasks and responsibilities between different members of the team. As mentioned by Anderson  et al. (2014), intra and inter-professional collaboration  within clinicians cam reduce the rate of occurrence of surgical site infections. The patients with obesity and chronic diabetes are at higher risk of SSI before and after surgery (Dubory et al., 2015).

The SSI occurs when microorganisms from instruments or theatre environment access the cut site after surgery. A number of effective practices have been suggested in order to reduce the chances of the occurrence of SSI. Some of the steps  which could be taken in this regard are- minimising tissues  damage during surgery and maintaining normothermia, using wound  dressings to  prevent the access of microorganisms  to the  wound site.  As mentioned by Tanner et al. (2015), precautionary measure needs to be taken to reduce the time and the amount of exposure to pathogens. For example, after colorectal surgery enterobacrteria are encountered this may increase the chances of contraction of SSI.

a number of  steps  could be taken for  prevention and management of  surgical site infections. As mentioned by Fan  et al. (2016), depending upon the physiology of the patient the rate of recovery of the patient could be predicted.  For example a patient with high body mass index often has exudation of tissue masses after surgery. It has been reported that almost 15% of the open wounds are treated inappropriately with antibiotics surgery (Tanner et al., 2015). Thus, careful monitoring and communication is required between various members of the multidisciplinary team such as surgeons, microbiologists and nurses.

In order to reduce the chances of SSI a number of essential steps could be followed such as maintaining normothermia,  glycemic control,   timely antimicrobial prophylaxis, appropriate hair removal prior to surgery. Some of the evidence based interventions have further focussed upon inclusion of supplemental oxygen, chlorhexidine gluconate pre –admission cleansing, maintaining separate surgical tray for fascia and skin closures, adequate administration of oral antibiotics (Scarborough, Mantyh, Sun & Migaly, 2015).

The presence of conditions such as diabetes type 2 further increases the time of healing   for the patient. Additionally, factors such as hand hygiene play a special role in controlling the rate of infection (Ponce et al., 2014).  It has been mentioned in the ACORN standards  that  the nursing professional should wash their  hands before and after handling a patient. However, as argued by Leaper, Tanner, Kiernan, Assadian & Edmisto (2015), this basic line of evidence is not sufficient and using alcohol rubs for complete disinfection has been widely advised. There is often neglect among the medical staffs in following as well as implementation of the exact clinical guidelines, which increases the chances of SSI. Some of these should be available in the operation theatres in the form of display reminders. However, the lack of sufficient training to the health care professionals along with lack of effective infrastructural and control setup can increase the chances of contraction of surgical site infections manifold times. In this respect, infection control program could be setup involving active engagement of infection surgeons and infection control staff.

Evaluation of the research articles

The research articles could be further evaluated for the effectiveness of the clinical methods and interventions in controlling the SSIs.  The articles evaluated over here have placed the importance upon aspects such as situation awareness. The situation awareness aspect could help the healthcare professionals take care of important aspects within a post-operative care environment such as implementation of aseptic techniques. However, the literature lacks much wide spectrum discussion of the aseptic techniques and the limitations faced in the implementation of the aseptic methods and protocols. In the lack of sufficient infrastructure the hospital may find the implementation of effective evidence based techniques difficult. Additionally, lack of motivation and support from the surgeons or the nursing heads further hampers the quality of care. Though, the concept of team self awareness have been highlighted over here. The lack of cooperation between different team members often affects the quality of care and supervision offered within a intensive care unit.

Additionally, the lack of sufficient infrastructure hinders the provision of effective provision of asepsis training to the healthcare professionals. As mentioned by Gillespie  et al. (2015),the  multifaceted approach of the care bundles further makes the identification of the critical factors  responsible for reducing the rate of SSI difficult. Hence, effective practical based experiences can help in enhancing the skill sets possessed by the healthcare professionals working in a post –operative setup.

The literature used rightly places importance upon the physiology of the patients undergoing surgeries for effective prevention methods which needs to be employed. For example patient with high BMI index often take greater amount if time in recovery. Additionally, the wound take longer time in healing within the obese patients (Inui & Bandyk, 2015). Therefore, greater prevention measures should be taken around the patients.  However as supported by Keenan  et al. (2014), most of the surgical site infections  are due  to  the  dissemination of Staphylococcus  aureus through the hands of the healthcare professionals. Therefore, implementation of effective infection control methods could have been beneficial. However as argued by Allegranzi  et al. (2016), the infection control methods are not fully effective as many strains of the  S. aureaus bacteria  are methicilin resistant.  Therefore, the gap within the control methods can enhance the chance of contraction of SSI. 

How well does the existing literature address your research question?

In answering this question consider if your research question has been a) fully answered, b) partially answered, or c) not answered at all. 

THEN identify a) what further research could be conducted (and its characteristics such as design, sample, outcome measures) that might provide important information to answer your research question AND b) what are some ethical considerations that apply to these possible research studies (approx. word count 400)

From the study conducted, it had been clearly identified that the main source of SSI was though the pathogens transferred through the hands of the healthcare professionals. Additionally, the post and peri-operative instruments   had also been taken into consideration. However, there are a number of gaps which have been found over here such as physiological factor such as the health condition of the patient should have been given more importance as less immunity enhances the chances of contracting infection. Additionally, the research fails to take some of other factors such as tiredness or compassion fatigue within the nursing professionals to be the causative factors for failure to follow the clinical guidelines (Hennessey et al., 2016).

Therefore, in order to overcome the research gaps an experiment could be setup where a survey could be conducted to gather patient and clinicians data regarding the quality of healthcare services provided within an intensive care unit.  The questionnaire could be designed based upon the different parameters of infection control.  The data collected from the patients could be collated with that of the health care professionals to analyse the quality of asepsis methods followed. The responses could be used for the generation of statistically significant results. The data could be collected from a small sample group of patients. However, consent taking serves important criteria over here.

In designing of the survey design, a number of ethical considerations need to  be taken into consideration. For example, the patient and their respective family members should be made to sign the consent forms before stating the interview process with them. The interviewer should ensure that privacy standards are maintained throughout the interview process and at no stage the confidential details of the interviewee are leaked out.  The interview data should be presented in an anonymous manner as the r4eal identity of the patient should be not be leaked out. Additionally, permission form should be sent by the researcher to the hospital authorities. In the lack of effective support from the hospital authorities conducting the interview becomes difficult. It often becomes difficult for the researcher to collate actual or sufficient data being at an arm’s distance from the organization.  Therefore, the findings presented by the researcher are subjected to confounding biases.  Therefore, in order to remove the biases the data collected through research needs to be collated with secondary research and journals.